Typical Reasons For Denial of A Workers’ Compensation Claim

Unfortunately, insurance companies do not accept every application of coverage, when it comes from an injured worker. Far too many requests for workers’ compensation get denied. Below, the reader can learn about the most common reasons for such a denial.

Basic requirements for any application that has a hope for being accepted

• The applicant was an employee of the insured company when he or she got hurt.
• The employer had purchased workers’ compensation insurance.

Possible reasons for a denial

When the employer was injured, he or she was not carrying out a task that would have benefited the employer. If the injury was sustained while the employee was taking a break, the denied applicant would need to prove that he or she had been reading some literature related to a company project at that time, or had been speaking with another employee about a company project.

The injury did not take place during working hours. For instance, the employee might have been injured during his or her commute. The injury was caused by misconduct on the employee’s part. Personal Injury Lawyer in Medicine Hat gives examples of misconduct would be consuming alcohol or using drugs during working hours, carrying out an activity for the purposes of self-amusement, or creating a self-imposed injury.

A given worker’s pre-existing condition has been pointed to as the primary cause for the same worker’s reported medical condition, the one related to the injury. Whenever this has been given as the reason for a denial, the denied applicant normally gets scheduled for an independent medical exam (IME).

The reported injury has been classified as one that is not serious. The best way to keep from being denied coverage for that particular reason relates to the injured employee’s behavior. He or she should seek medical help as soon as possible. Such an action reduces the strength of a claim that the injury was not serious.

More on the benefits of seeking medical help as soon as possible:

If someone with a pre-existing condition seeks medical help soon after getting injured, that help will probably not come from someone that specializes in that worker’s pre-existing condition. The first diagnosis might suggest that the same worker has a relatively minor medical problem.

If that proves to be the case, it helps to contact a lawyer, and to have the lawyer contact the facility that made the incorrect diagnosis. The lawyer should then share some basic facts about the patient’s/worker’s medical history. Ideally, the contacted physician would acknowledge the wisdom behind consulting with a specialist. If a specialist gets seen soon enough, the insurance company might have little reason for scheduling an IME. The words of a specialist hold more weight than those echoing an insurer’s contentions.